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rUK Urr.ica u5t: .. <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------------------- Permit No. f-,�/7 <br /> (Complete in Triplicate) ----"`-' <br /> --------------------------------------------------------- <br /> ----------------------------------------.-------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and inst a wor erein <br /> described. This application is 'm/addee in compliance with County Ordinance No. 549 and existing Rule and Regulations. <br /> JOB ADDRESS/LO TION/ ?T/l,_j --------------------------------------------CENSUS TRACT ------------- --- <br /> Owner's Name -,--r- -- ------------------------------------ _---..-------------Phone ---...--- <br /> Address - City ------------ '" " <br /> Contractor's Name --------- ;1ti- --- ------- -- - ----= -.r _ _ .-License # w-2 Phone ------------------------------ <br /> Installation will serve: Residence Ap rtment House-E] Commercial [-]Trailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:-----l----- Number of bedrooms j_-_-Garbage Grinder _-y------ Lot Size 41111-'�A_9"_ �___ --------------------- <br /> Water Supply: Public System and name ------------------------------------------------ ----•---------------------------------------- -------------Private LT <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay (Peat❑ Sandy Loam ,F] Clay Loam <br /> Hardpan [3- Adobe's Fill Ma �idl ---- ___Jf yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location of__systerfti in-relation to wells, building.s,, etc.',must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank;or:: e ge pit permitted i# public sewer isRa dilabl4within 200 feet,) ` <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size _-_X_1Q.._ '_s-__---___-_ Liquid Depth ---_____________._____ <br /> Capacity, p n_._._.. Type -• ___ Material_( fit` _-,_-- No. Compartments .-(:;A-------- ---- <br /> e � ,r <br /> bistance to nearest: Well - --------- 0---------- ......Foundation-___/_O________ Prop. Line -_ ___---_`----_ <br /> LEACHING LINE [ No. of Lines ------A--------.--- Length of each',Iline------/_f�P_- -..__-__ Total Length ----- q_90---- <br /> 'D' Box _:._.___ Type Filter'Material ._Z.9__ Depth Filter Material ----_f�__��_______________ <br /> ff-------- <br /> e <br /> Distance o nearest -W�11-_____:___ -:-- Foundation ____-_J B._.._._.. Property Line -___sT_ __ ---------- <br /> Y <br /> SEEPAGE PIT [ Depth _...o ._S rC] <br /> Diameter ________________ Number _____.___ Rock Filled es No <br /> Water Table Depth ----------------------#-o---------------------Rock Size ----IA-,X__3------------- <br /> � <br /> Distance to nearest: Well ---------------NP-P-_t___________---Foundation -------1_a-c_ — Prop. Line ----4.............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -------------------------------------------------•--------------- ----------------------------------_------•-- <br /> Disposal Field (Specify Requirements) ------ ------•----------•------•-------------------------•--- ----------------------------------------------------------------------- <br /> •------------------------ ---------------------------------------------•-------------------------------------------------------------•------------------------------- ----------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject _ kman's Compensation laws of California." <br /> Signed ----------- ---- --- Owner <br /> By ------ ----- Title ---- <br /> P ..... . <br /> (If of er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...'_,/ DATE ^ _ --------- <br /> `_. _�� _ .. <br /> - ---------------------------------------- <br /> BUILDINGPERMIT ISSUED ------------------------------- ----------------------------------------------------------- --------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS -------- ---------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> _______ _____ ______ ` _ F4 <br /> Final Inspection by: ,� ---------•--------•-- = f Date... <br /> ---------------------- <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />